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Type:
Change Request
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Resolution: Unresolved
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Priority:
Medium
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FHIR Core (FHIR)
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R4
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Financial Mgmt
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(NA)
Add the following values to the Code System Adjudication:
| Code | Display | Definition |
| coinsurance | Co-insurance | The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. |
| noncovered | Noncovered | The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. |
| priorpayerpaid | Prior payer paid | The reduction in the payment amount to reflect the carrier as a secondary payor. |
| paidbypatient | Paid by patient | The amount paid by the patient at the point of service. |
| paidtoprovider | Paid to provider | The amount paid to the provider. |
| paidtopatient | Paid to patient | The amount paid to the patient. |
| memberliability | Member liability | The amount of the member's liability. |
| coupon-discount | Coupon discount amount | Coupon discount reducing the amount to be collected from the patient |
| member-discount | Member discount amount | Member discount reducing the amount to be collected from the patient |
| other-discount | Other discount | Other discount reducing the amount to be collected from the patient |
| discount | Discount | The amount of the discount |
| drugcost | Drug cost | Price paid for the drug excluding mfr or other discounts. It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration |
| other-cost | Other cost | Other amount to be collected from the patient |
See attached Excel providing the comparison of the current Adjudiation Code System and those defined by CARIN BB and RTPBC. These IGs define the the following Code Systems:
http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-patient-pay-type